Drugs heal, drugs hurt.

There are those who use drugs, and there are those who could, potentially, benefit from drugs. The two groups do not always coincide:

The blue circle represents those who could, potentially, benefit from drugs. The red circle represents those who actually use drugs. The intersection of the two, shown in purple, represents the sphere where drugs heal, the appropriate use of medications.

The two crescents represent millions of incidents of human suffering. The crescent on the left represents those who do not get the drugs that could, potentially, help them. It contains those without the resources or the skills needed to negotiate the medical system, articulate their needs, and get what they want, and those who simply refuse to seek help.

The crescent on the right represents the inappropriate use of medication: Ritalin or Adderall being used as study aids, or to boost exam performance; the use of antibiotics to treat viral infections; people taking anti-depressants when non-pharmaceutical treatments, such as exercise, diet, and vitamin D would work as well.

The crescents on the right and left are mutually exclusive in the picture, but are intimately related in reality. Those who become addicted to recreational drugs, such as alcohol, are often "self-medicating", trying to deal with underlying mental health issues. Overuse of some drugs is the flip side of underuse of others.

Anyone who has experienced the hurt created by the misuse of drugs just wants it to stop. The instinctive reaction is to use top-down methods of control. As a society, we use a variety of methods to shrink the red circle: we ban some drugs, tax others, and make accessing and consuming drugs more difficult by, for example, forbidding the consumption of alcohol in public places. Other policies attempt to both shrink the red circle, and move the blue and red circles closer together. Education is one such policy, but the more important one is gatekeeping. Physicians, pharmacists, other medical professionals, as well as governments and insurance companies, all limit and control access to medication.

For highly addictive and harmful drugs, such as crack cocaine, there is a case for intervention, possibly even prohibition. If I tried crack cocaine even just once I might get addicted, and that could ruin my life, so I'm happy that the sale and consumption of crack cocaine is banned.

But I'm not convinced that we're adopting the best gatekeeping strategy for prescription drugs, especially those used to treat mental illness. According to the recently released Mental Health Strategy for Canada, "only one in three people who experience a mental health problem or illness—and as few as one in four children or youth—report that they have sought and received services and treatment."

The undertreatment problem could be ameliorated by putting more money in the system: providing greater financial support for medications and counseling, for example. Yet the health system is already strained financially, and treatments such as one-on-one counselling are very expensive.

The patient model that characterizes much of health care - follow the doctor's orders - doesn't work for everyone. The Mental Health Strategy talks about giving patients more say, allowing people to be "empowered to make informed choices about the services, treatments and supports that best meet their needs." But how far can patient empowerment go? How about allowing people more say in choosing their own medications and prescriptions. For example, suppose that one could get a prescription for Prozac by going to the local local pharmacy and asking for one, instead of going to a doctor first.

The idea is not as off the wall as it might at first appear. Ontario's Drummond Report plays with it: "Suppose that pharmacists played a greater role in issuing prescriptions." Honestly, how often does a doctor, presented with a patient describing the symptoms of depression, do anything other than say "exercise - vitamin D - vegetables - sleep - here's a prescription"? Are there any circumstances when a pharmacist would issue a prescription that a doctor wouldn't? Any times when a doctor knows more about the potential side-effects of medication than a pharmacist? Indeed, if pharmacists could issue prescriptions, doctors might feel less pressure to do so, and be able to devote more time to, say, providing counselling for patients. If just one life was saved because someone was able to get anti-depressants when they needed them, instead of having to wait for a doctor's appointment, wouldn't it be worth it?

More radically, why not dispense with gatekeepers entirely, and make anti-depressant medications available over the counter? To an economist, making drugs available only through prescription - like any other policy that restricts people's choices - requires justification. Underpinning much of economics is the assumption that people are rational decision-makers, the best judges of their own well-being. People, in this framework, will only make the wrong decision in specific circumstances: when they fail to take account of the effects of their actions on others; when they lack information; when (drawing upon behavioural economics) their decision-making process are flawed. People succumb to temptation and peer pressure, for example, or do a poor job of estimating the risks inherent in their choices, or fail to plan for the future.

Thirty or forty years ago, one could reasonably assume that doctors knew more about the available prescription medications, their appropriate use and side-effects, than patients. This information asymmetry justified the system of medication-by-prescription that we have today. But does this assumption still hold? There are so many different medications on the market that the average busy family doctor cannot possibly know the ins and outs of all of them. The internet puts information in the hands of the patient, allowing him or her to make informed choices. The informational case for requiring prescriptions is weaker than it was.

There is an additional argument for the prescription system, however: equity. Prescription medications are covered by many health insurance plans, hence the cost of prescriptions are shared across the population. When drugs are sold over-the-counter, however, each person must pay for his or her own medication, and the amount of risk-sharing is diminished. The flaw in this logic is that many people do not have health insurance, so pay for their own pharmaceuticals directly. When people pay for their own medications, they are more concerned about the price, so making more treatments available over the counter could exhert downwards pressure on prices.

Honestly, I'm not sure about the wisdom of throwing open the medicine cabinet. But I am sure that too many people are falling through the cracks with our current system.

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"Only one in three people who experience a mental health problem or illness—and as few as one in four children or youth—report that they have sought and received services and treatment."

Bingo. The biggest problem with mental illness is that we, as a culture, don't want to admit we have a problem or just will it to go away. Mental illness is therefore a manifestation of a failure of will, or some other value judgment.

Second, many anti-depressants are themselves "addictive", you can't stop them cold-turkey, you'll go through withdrawal. If I miss my pills I feel it very quickly and it is very unpleasant (the med has a short half-life). So medical supervision is required. In order to get off anti-depressants you have to back away slowly. Further, the most dangerous point of treatment for a depressive is just after the meds start working. Energy is known to improve before mood and therefore the still-despondent person has more energy to commit suicide. That's why it's so dangerous.

"If just one life was saved because someone was able to get anti-depressants when they needed them, instead of having to wait for a doctor's appointment, wouldn't it be worth it?"

That's not how anti-depressants work. They take time to kick in, often three weeks. Neurochemistry has significant inertia. There is a strong placebo effect which can lead to a let-down, which is why the first stages of treatment have to be monitored.

Anti-depressants are not like insulin which works within 30 minutes of injection.

"There is an additional argument for the prescription system, however: equity. Prescription medications are covered by many health insurance plans, hence the cost of prescriptions are shared across the population. When drugs are sold over-the-counter, however, each person must pay for his or her own medication, and the amount of risk-sharing is diminished. The flaw in this logic is that many people do not have health insurance, so pay for their own pharmaceuticals directly. When people pay for their own medications, they are more concerned about the price, so making more treatments available over the counter could exhert downwards pressure on prices."

Sounds more like an argument for universal pharmacare of the type they have had in the UK since 1948. Honestly, as a diabetic the insulin is more important than the doctor. But then again pharmacare is why I joined the NDP.

Phil: if you've ever marked undergrad exams, you would know that students are far from rational decision makers!
More seriously, lack of information often means that people are not able to best judge their own well being. It is difficult to accurately weigh the risks and benefits if you don't even know what the risks are.

This is a good post, and it's a long post, so I understand if it's current length was a limiting factor. However, if you're going to discuss the potential negatives associated with this policy you should discuss why it hasn't (won't?) happen: Canadians hold physicians in too high a regard, and Canada's medical associations prioritize the earnings potential and power of physicians to too high of a degree, to allow major rollbacks in the corner of the economy designated 'for MD's only'.

The ongoing slow adoption of nurse practitioners provides a template for the public discussion. Reformers will argue that there is an alternate way of running the healthcare system that is cheaper, provides more choice, and is probably just as effective (if not more so) than the status quo (though there is no direct evidence, because we have not made the change yet). The representatives for physicians' collective interests will argue that the change will 'kill' because nothing can replace one on one contact with your local GP, that there is no proof that the change is safe, and that it is a measure that puts dollars ahead of lives.

Have you ever actually noticed how organized some pharmacies are? Not very. I file my prescriptions when I get them from the doctor so I don't lose them and then the pharmacy has lost them. Now I keep photocopies. It's a common problem, doctors know pharmacists are often klutzes when it comes to filing.

Determinant: "So medical supervision is required." You're absolutely right about the suicide risk associated with anti-depressants. But there's also a suicide risk associated with untreated mental health problems.

My experience in Ottawa - which admittedly has a bit of a physician shortage - is that it's up to the patient to go out and actively solicit follow-up treatment. The doctor's office will never call and say 'how are you doing, you it's time to come in for your annual check-up' or anything like that. So sure, the best of all worlds might be the kind of loving hands-on care that my dog gets from his vet. But I'm not sure that this option is on the table.

Failing that, don't you think that, at least for some conditions - like your diabetes - patients might do as good a job of managing their own care as the professionals do?

Phil - It's true that what one person thinks is a personally legitimate use of a drug, another person might consider abuse. E.g. is it o.k. for an 18 year old to have a beer in order to relax of an evening with friends? In the UK, in Quebec (and Alberta??) the answer to that question is yes; in the rest of Canada and in the US the answer is no.

My concern with performance enhancing drugs in general is that they raise the bar, and so others have to take them in order to remain competitive - which is a problem to the extent that these drugs have harmful side effects.

arrow: "if you're going to discuss the potential negatives associated with this policy you should discuss why it hasn't (won't?) happen"

Good points. Though Alberta has actually adopted a policy along these lines, and others have toyed with legislation allowing pharmacists greater prescribing powers.

Determinant - I'd say that the average pharmacy is much more likely to have electronic medical records than the average doctor's office.

I'd say electronic health records are orthogonal to the case. My pharmacy has a central computer for patient files; you can order over the phone through an automated attendant for a refill, I often do. But if they misfile the original and it never got into the system you are still sunk.

My family doctor has electronic records now and has had them for five years or so. She is also part of a Family Health Team, the clinic as a whole has plenty of work so they appreciate efficiency. Another city with physician shortages.

But my physician cannot e-mail my prescription to my pharmacy, I have to carry in the paper by hand and it has to be manually entered on their system. Which is a fault of the legal system, I think, for requiring hard signatures.

I don't know what you've experienced in Ottawa, my family doctor books follow-up visits if needed when you leave the original appointment.

I figured out the high violence rate of crime in rich AB is alcohol availability. I like the single beers though. I'd rather have our geniuses and artists having all the drugs they want than CPC policies. What about paying to be confined to house arrest for some drugs and some sort of vital signs monitoring? If you aren't given enough to OD. @#$% I'd like some drugs now. I hate this thread. You can have junkies use a time lock safe to get their pills. Just have to pay for it. Heroin and crack cocaine are about the only drugs I think should be illegal for adults mid-20s and up.
In the future, one option for safely administering and maybe even for everyone if we all become engineers of, dangerous technologies, is to use drugs or brain implants or manchurian candidate hypnosis and brainwashing, to prevent us from killing eachother. Addictive drugs and a N.Korea style dictatorship being the downside. We will also need to know when a person has become too much a super-villian, too junkie-powerful to stop...
We won't get there by electing PMs who attend Fundamentalist Christian Church or practise Wahhabi Islam.

If I tried crack cocaine even just once I might get addicted, and that could ruin my life, so I'm happy that the sale and consumption of crack cocaine is banned.

I think such this kind of statement is baffling. But for the law, you would be hooked on crack cocaine? Am I the only one who makes decisions for myself independent of what the law happens to be?

There is an additional argument for the prescription system, however: equity. Prescription medications are covered by many health insurance plans, hence the cost of prescriptions are shared across the population. When drugs are sold over-the-counter, however, each person must pay for his or her own medication, and the amount of risk-sharing is diminished.

I'm not so sure "equity" is a good name for this argument. If people pay for their own medication then everyone has equal access to medication under the law. I tend to get frustrated when people equate income inequality to inequity. Allowing all individuals an equal chance to pay for a market good is infinitely more fair than using the law to ration life-saving medication.

Ryan - "I'm not so sure "equity" is a good name for this argument." It's essentially a benefits-of-insurance type argument. There but for the grace of God go I. So call it insurance rather than equity if you wish.

"But for the law, you would be hooked on crack cocaine?" - Probably not, but I might be. I can imagine being at a party, being drunk, having someone hand something to me and say 'try this' and me - trusting and naive - saying 'sure, what harm could it do?' True, making crack cocaine illegal doesn't prevent that from happening. But to the extent that making something illegal reduces the quantity of it about/raises the price of it - which is not obvious - I'm less likely to be exposed to crack cocaine if it's prohibited.

The whole point of highly addictive drugs is that they interfere with your ability to make decisions for yourself - someone can deceive you into taking it once, and then you're done for.

Maybe crack - which is the drug of choice among hobos - is a bad example here. The law hasn't put the price out of reach for the poorest among us. If you tend to try things at parties without really understanding what those things are, then I'm not sure a law governing the substance in question offers you much protection. Maybe because I have food allergies and diabetes, I've just been conditioned to ensure that whatever someone holds out to me isn't going to kill me.

I do get what you mean that "an argument could be made" for keeping such drugs illegal, but on the other hand if prescription medications were accessible over-the-counter, and hobos could buy their own antipsychotics (which is what they REALLY need, for the most part), or charities could buy them and dispense them directly to hobos, then crack use in general would plummet, even if legal.

Ryan: "if prescription medications were accessible over-the-counter, and hobos could buy their own antipsychotics (which is what they REALLY need, for the most part), or charities could buy them and dispense them directly to hobos, then crack use in general would plummet"

This thought is what was really driving this post. Alcoholism, for example, causes so much pain for so many people, and a lot of the time it's caused by people self-medicating their depression/anxiety. We have to trade off overuse of over-the-counter prescription medication against overuse of the alternatives, e.g. alcohol.

I am one of those who agrees with expanding the prescription franchise to other professionals--as well as making more drugs OTC--but I think the argument is mostly supported by the likelihood of getting the prescription faster. I don't think there is a strong argument that the expansion would make pharmacotherapies better, that is, more effective in treating symptoms with the right drug. If pharmacists (or NPs) are prescribing even half the number of drugs that a family doctor can write scripts for, it is still unlikely that they will be doing a really thorough diagnostic procedure, overall health evaluation, family medical history, etc etc. In other words, I think you are as likely to be put on anti-depressants too readily or for too long with a nurse practitioner or pharmacist, as you are with a family doctor.

The issue is twofold: getting a correct diagnosis and then selecting the right treatment, and having enough resources to carry out those functions with reasonable speed. The first problem is usually solved helped by establishing clinics (multidisciplinary teams), where having many minds involved and making clinical practice more visible to peers can reduce error (including overuse of drugs). But obviously this costs more, and does not solve the second problem.

@ arrow (Kenneth??) I hear you on the MD rent-seeking, but I disagree that adding more professionals to the mix improves quality. The question in the appropriate administration and management of drug therapy is, what is the typical profile of professional error? Generally speaking, it includes solitary or unsupervised practice, no quality evaluation or feedback loop, limited ability to consume new information, and overconfidence. I see no evidence in other settings that these are substantially lower with other types of professionals. The issue is one of organizational structure.

Shangwen - you're in Alberta, aren't you? The scope of pharmaceutical practice in Alberta is much wider than in the rest of Canada. Do you have any sense of whether or not that makes any difference? Given what you've said, I suspect your answer is - not much.

I do get what you mean that "an argument could be made" for keeping such drugs illegal, but on the other hand if prescription medications were accessible over-the-counter, and hobos could buy their own antipsychotics (which is what they REALLY need, for the most part), or charities could buy them and dispense them directly to hobos, then crack use in general would plummet, even if legal.

Over the counter or not really isn't the issue, price is. Hobos by definition do not have money and don't have regular incomes and therefore can't comply with treatments easily. I don't see how reducing MD involvement lowers the price, the answer is universal insurance. Ryan has stated he is a diabetic so I trust he knows exactly the value of insurance in treatment compliance.

Further, the issue of self-medication with booze will not be solved by making anti-depressants easier to get. (As I have stated, they have to used correctly, have serious withdrawal and take time to work. They are NOT a quick fix. Insulin IS a quick fix.) Our culture is reticent about admitting mental health issues and self-medication with alcohol is a socially acceptable way to behave, to a significant degree. It is more acceptable than admitting you have a problem and seeing a doctor about it. It is really difficult to get people to that epiphany point.

Shangwen:

Agreed about clinics. For what it's worth, the single lone practitioner model appears to be dying in Ontario. Clinics and family health teams are the way it is done now. Between the office costs, the overhead for nurses, assistants and clerks, the greater ability to schedule vacations with clinical teams and the province's nudge for physicians to form health teams, the lone practitioner is a dying breed in Ontario. Some people mourn its passing but as you point out, that model had deep flaws.

Determinant: "Further, the issue of self-medication with booze will not be solved by making anti-depressants easier to get."

It's about being in control, having some say over the course of one's treatment. The traditional doctor/patient model puts all of the control/power in the hands of the doctor. That's something that needs to be rethought, IMHO.

In my actual experience, anti-depressants aren't a cure-all. I take the things, have an actual psychiatrist (you have to be really bad to get that far) and for anti-depressants to work properly, they need to be taken properly, their side-effects monitored and the patient needs social therapy and exercise. Attaining self-control helps depression a lot, but anti-depressants are not an instant happy like a food pellet from a dispenser in an experiment with rats.

Further, different people react differently to different drugs, anti-depressants are a class with many choices.

For that matter, insulin goes to work in 30 minutes and has a very specific path that it works in. It exits the system in hours and a patient who can do a blood test is in a better position to monitor themselves than doctors. Actually that may be why insulin can be bought over the counter, but it mostly isn't because insurance plans demand prescriptions before they pay for the purchase. If you can tell when you have a high bloodsugar and a low bloodsugar and know which insulin to adjust to get the best effect, you're off to the races.

Or put a different way, anti-depressants aren't like water which cures thirst instantly. They are more complex and hazardous than that.

Lots of doctors encourage patients to be pro-active, such patients are easier to work with and follow treatment more closely if they are engaged and convinced of the necessity of the proposed course.

I did a quick search on PubMed and the tentative finding in Canadian publications seems to be that expanding the prescription base to pharmacists increases access but does not affect quality (but my comment would be that more access to mediocre care is better than no access, cost aside). A couple of others seem to suggest the same thing. The problem of improving the effective allocation of medications has a lot do with institutional issues more than it has do with the supply of prescribers, the cost of drugs, or credentials.

On the topic of street drugs, I tend to fall severely on the libertarian side. Prohibition doesn't work, and I think the risk of a few more addicts being created (and their lives being destroyed) is, sadly, worth the risk of a huge drop in all the violence, prostitution, and other crimes associated with the drug trade. And in any case, why should giving somebody a highly addictive drug like crack not be considered a form of assault?

My better half worked for a research group looking at complementary and alternative medicine. From a scientific/evidence based perspective, most of it is crap. So why do people seek it out anyway? Are people stupid? Of course, in some cases they are simply desperate. In general though, it turns out that the patients prefer the user experience. The CAM practitioners listen, take more time, show more sympathy with the patients struggles. The process matters at least as much as the effectiveness of the treatment.

Which reminds me of a story I read about rabbits in a lab: A pharmaceutical company was doing some testing on rabbits, and they found that the rabbits housed in one particular room were living much longer and had much different outcomes than all the other rabbits in the study. The company investigated and found that the only difference was that the technician who cared for the rabbits in the room in question would take every rabbit out of its cage and pat it for a few minutes.

Just a quick quip; "If just one life was saved because someone was able to get anti-depressants when they needed them, instead of having to wait for a doctor's appointment, wouldn't it be worth it?"

Worth what? The two scenarios I see presented (A - Pharmacists can prescribe anti-depressants or B - there are no constraints on pharmaceuticals) have opportunity costs that should be considered.

Scenario A - [I'll ignore this for now; it probably makes sense for a wide class of drugs - the challenge is in the diagnosing not the medication per se.]

Scenario B - If there were no constraints on pharmaceuticals, I would expect the manufactures to develop risk-aversion strategies leading to drugs with minimal side-effects (and therefore minimal liability) but also potentially avoiding truly effective drugs for non-common conditions. (I forget the name of the drug, but there is a seizure medication for with a relatively low-risk of death; this drug is occassionally used off-label for sleep disorders. Would this drug be produced if the manufacture thought students would be taking it to help them cram for exams? It's nice to say "the person should have known better" but Macdonalds was sued for selling hot coffee...)
So is the easy access to low-risk drugs worth the avoidance of high-risk drugs?

@Peter: McDonald's was not sued for having served hot coffee. It was sued for tampering with the safety features of a machine, against the manufacturer instructions, and causing third-degree burns. And this case being one of more than 700 instances of such burns...